CareCentrix Decommissioning
Effective March 31, 2025, health coaching, authorization support for post-acute care, and sleep services performed by CareCentrix® will be transitioned to Sentara Health Plans. The network for Home Infusion services will transition from CareCentrix network to the Sentara Health Plans network.Diagnosis to Modifier Mismatch - Policy Update
According to the ICD-10-CM manual guidelines, some diagnosis codes indicate laterality, specifying whether the condition occurs on the left or right, or is bilateral. The diagnosis-to-modifier comparison assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis.Therapeutic Shoes without Diabetes Diagnosis - Policy Update
Diabetic shoes and inserts are covered expenses for adults over the age of twenty-one (21) when medically necessary and submitted with an ICD-10 code for Diabetes (ICD-10 E08.00-E13.9).Zelis Payment Network - Provider Payment Processing
Provider payment processing is transitioning to the Zelis Payments Network.OncoHealth to Administer the Oncology Benefits Program - Operations Update
OncoHealth will administer Sentara Health Plans' Oncology Benefits Management Program.Genetic Testing Management Partnership Implementation - Operations Update
The Genetic Testing Management (GTM) program includes new and revised medical policies, a new authorization request process, guidelines, and consistent preservice reviews for certain genetic testing services that will be applicable to both ordering and rendering provider partners.OncoHealth to Administer the Oncology Benefits Program - Operations Update
OncoHealth will administer Sentara Health Plans (SHP) Oncology Benefits Management Program.Quest Diagnostics - Operations Updates
Effective January 1, 2025, Quest Diagnostics will become the exclusive independent laboratory vendor for Commercial and Government programs.23-Hour Crisis Stabilization Services - Regulatory Update
Department of Behavioral Health and Developmental Services (DBHDS) is requiring that providers of 23-Hour Crisis Stabilization services obtain one of the following licenses: (i) MH Center-Based Crisis Receiving Center for Adults (02-040) and/or MH Center-Based Crisis Receiving Center Children and Adolescents (02-041). Providers of 23-Hour Crisis Stabilization are required to do all the following actions by December 2, 2024.Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid Enrollees
Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid EnrolleesReminder-Billing and Coding JW and JZ Modifiers
Sentara Health Plans complies with CMS requirements for the use of modifiers JW and JZ on single-dose container drugs.General Anesthesia Rendered in Place of Service 11 (Office)
Sentara Health Plans does not cover general anesthesia when rendered in place of service 11 (office).Inappropriate Use of JW Modifier
Sentara Health Plans will deploy an edit to review the inappropriate use of JW modifier (drug amount discarded/not administered to any patient). The JW modifier is only permitted to be used to identify discarded amounts from a single vial or single package drug or biological. It is inappropriate to append JW modifier to a multi-dose vial (MDV).Service Rates Increase for ABA Services
Effective September 1, 2024, Sentara Health Plans will increase commercial rates for ABA services to align with DMAS. Our contracting processes were modified to automatically apply rate changes as they are released.Authorization Requirement Removed for Electroconvulsive Therapy (90870)
Authorization requirements for Electroconvulsive Therapy (ECT) 90870 was removed. Providers should provide the service to members and file a claim for reimbursement